RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  	CASE:  PD1201664
BRANCH OF SERVICE:  Army	BOARD DATE:  20130430
SEPARATION DATE:  20031220

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty PFC/E-3 (95B/Military Police) medically separated for irritable bowel syndrome (IBS) and tibial and fibular stress fractures/reactions, respectively.  Within weeks of enlisting, the CI sought treatment for multiple complaints to include knee, leg, ankle, back, chest, abdominal and kidney pain.  She also complained of headaches and diarrhea.  Ultimately she was diagnosed with IBS.  Additionally, a bone scan in July 2003 showed a left proximal tibial stress fracture and bilateral periosteal stress reactions in the fibula.  Her conditions could not be adequately rehabilitated to meet the physical requirements of her Military Occupational Specialty (MOS) or satisfy physical fitness standards.  She was issued a permanent P3/L3 profile and referred for a Medical Evaluation Board (MEB).  The conditions characterized as MEB diagnoses 1) “irritable bowel syndrome”, 2)“stress fracture left tibia and fibular stress reactions with pain”, and 3)“lower abdominal pain and low back pain”, were forwarded to the Physical Evaluation Board (PEB) IAW AR 40-501.  No other conditions were submitted by the MEB.  The PEB adjudicated the IBS, subsuming the 3rd MEB diagnosis, as unfitting, rated 10% and adjudicated tibial and fibular stress fractures, as unfitting, rated 0% with likely application of the Veteran’s Affairs Schedule for Rating Disabilities (VASRD).  The CI made no appeals, and was medically separated with a 10% combined disability rating.

CI CONTENTION:  The CI simply stated, “lumbar strain (lower back condition) should have also been general Residual left/right stress fractures-major leg issue & pain could have walk at times inflicted due to training & the fall.  Back pain & discomfort needing to ice/heat my back lower (lumbar & cervical) daily.  Abdominal pelvic pain. I am unable to have children.”  The CI also refers to bronchitis, pneumonia and neck issues which she believes should have been compensated for. 

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44, Enclosure 3, paragraph 5.e. (2).  It is limited to those conditions determined by the PEB to be unfitting for continued military service and those conditions identified but not determined to be unfitting by the PEB when specifically requested by the CI.  The ratings for the unfitting IBS and tibial and fibular stress fractures are addressed below.  The requested low back pain is likewise addressed below.  The requested neck pain and bronchitis/pneumonia conditions were not identified and thus are not within the DoDI 6040.44 defined purview of the Board.  Any conditions or contention not requested in this application, or otherwise outside the Board’s defined scope of review, remain eligible for future consideration by the Board for Correction of Military Records.

RATING COMPARISON:  

Service IPEB – Dated 20031009	VA - (4 Mos. and 14 Mos. Post-Separation) 	
Condition	Code	Rating	Condition	Code	Rating	Exam	
Irritable Bowel Syndrome (for MEB DX lower abdominal pain and low back pain)	7319	10%	Irritable Bowel Syndrome	7319	10%	20040416	
			Lumbar Sprain	5237	10%	20050218	
Tibial and Fibular Stress Fractures w/o x-ray confirmation; w/o limitation of motion	5022	0%	Residuals, Stress FX LLE	5299-5262	0%	20050218	
			Residuals, Stress FX RLE	5299-5262	0%	20050218	
	Not Unfitting	No VA Entry	
No Additional MEB/PEB Entries	Other x 6	20040416	
Combined:  10%	Combined:  30%	

ANALYSIS SUMMARY:  The Board acknowledges the sentiment expressed in the CI’s application regarding the significant impairment with which her service-incurred condition continues to burden her.  The Board wishes to clarify that it is subject to the same laws for service disability entitlements as those under which the Disability Evaluation System (DES) operates.  The DES has neither the role nor the authority to compensate members for anticipated future severity or potential complications of conditions resulting in medical separation.  That role and authority is granted by Congress to the Department of Veterans Affairs (DVA), operating under a different set of laws (Title 38, United States Code).  The Board also acknowledges the CI's contention suggesting that ratings should have been conferred for other conditions documented at the time of separation and for conditions not diagnosed while in the service (but later determined to be service-connected by the DVA).  While the DES considers all of the member's medical conditions, compensation can only be offered for those medical conditions that cut short a member’s career, and then only to the degree of severity present at the time of final disposition.  The DVA, however, is empowered to compensate all service-connected conditions and to periodically re-evaluate said conditions for the purpose of adjusting the Veteran’s disability rating should the degree of impairment vary over time.

Irritable Bowel Syndrome.  The CI sought care for a constellation of symptoms to include abdominal pain that radiated to the low back, painful urination (dysuria), flank pain, and diarrhea alternating with constipation, in August 2002 weeks after entry into service.  Several diagnoses were entertained and after normal laboratory studies and a normal ultrasound of the pelvis gynecology recommended a surgical procedure.  A diagnostic laparoscopy was performed in February 2003 which revealed no clinical pathology of the female pelvic organs.  She was evaluated by gastroenterology in September 2003 and reported abdominal pain in the right and left lower quadrant, with occasional nausea, sharp pain, and dysuria, with alternating diarrhea/constipation.  She reported the last episode had been a week prior to this exam.  She additionally reported the pain was constant 4 of 10 in intensity that worsened with lifting, exertion and during her menstrual cycles and was not relieved with bowel movements.  The gastroenterologist diagnosed possible IBS which took a higher priority of the other diagnoses as stress seemed to be a major factor in the CI’s life.  She attempted multiple medications without long term relief.  The permanent profile identified both irritable bowel and chronic low back pain (LBP) with limitations to include, no running, jumping, marching; no lifting greater 20 pounds, no strenuous activity, a recommended 6 hour work day and office duty.  The commander’s statement corroborated the medical conditions and had no additional recommendations.

At the narrative summary (NARSUM) for the MEB exam the CI reported, due to all her medical problems, she had not been able to play sports.  The MEB physical exam, 4 months prior to separation, demonstrated abdominal tenderness without acute abdominal signs.  The NARSUM examiner diagnosed lower abdominal pain and lower back pain.  The examiner recommended the CI follow-up with nephrology and gastroenterology to look for other causes of her lower abdominal pain.  At the VA Compensation and Pension (C&P) exam, 4 months after separation, the CI additionally reported that she was never symptom free with vacillating constipation and diarrhea, and pain with bowel movements.  She was taking oral contraceptive pills (OCP) for the pain in lieu that it was gynecologic disease in nature.  She also reported taking a narcotic based pain medication, and two GI medications for her condition.  The VA examiner documented the CI was evaluated by a gastroenterologist after discharge who confirmed the IBS diagnosis.  The C&P exam demonstrated no new additional findings.

The Board directs attention to its rating recommendation based on the above evidence.  The PEB and VA both chose the same coding option for the condition, 7319 (Irritable colon syndrome) and assigned a 10% rating.  The rating criteria under the 7319 code are elaborated below.

Severe; diarrhea, or alternating diarrhea and constipation, with more
or less constant abdominal distress .....................................................................30
Moderate; frequent episodes of bowel disturbance with abdominal
distress .................................................................................................................10
Mild, disturbances of bowel function with occasional episodes of
abdominal distress .................................................................................................0

The Board agreed the evidence supports moderate pain distress, 4 of 10 in intensity, with intermittent severe abdominal distress for the 10% rating.  The Board also considered future VA rating decisions and notes the IBS rating remained 10%.  The Board considered code 7629 (endometriosis), a gynecologic disease, and notes while the evidence does not document laparoscopy diagnosed endometriosis, the CI was taking continuous OCPs for abdominal pain which supports the 10% rating criteria under this code.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the irritable bowel condition.

Tibial and Fibular Stress Fractures Condition.  The NARSUM notes reflected that the CI sought care for lower leg pain in July 2002 which persisted despite anti-inflammatory medications.  She was diagnosed with bilateral shin splints in November 2002 and placed on a no run profile in May 2003.  A bone scan in July 2003 revealed a left proximal tibial stress fracture and bilateral periosteal stress reactions in the fibular.  The permanent profile identified the left tibia stress fracture with appropriate limitations as noted above.

The MEB physical exam 4 months prior to separation, demonstrated tenderness in the right anterior tibia.  The C&P exam performed 4 months after separation, was silent to a historical review or exam of this condition, and however did have plain X-rays evidence of the bilateral tibia and fibula which revealed no evidence of a fracture or other bony abnormality.  At the C&P exam, 14 months after separation, the CI reported bilateral shin pain 1-2 times per week, aggravated with exertion, but she was able to walk 3 miles.  She reported not receiving any treatment.  The C&P exam and X-rays were normal.

The Board directs attention to its rating recommendation based on the above evidence.  The MEB exam is the most complete proximate exam for this condition prior to separation and therefore the Board assigns it the most probative value.  The PEB and VA chose different coding options for the condition, but this did not bear on rating.  The Board notes the PEB is not specific if the condition is unilateral or bilateral yet the permanent profile specifies a left stress fracture condition.  The Board notes the bone scan evidence supports a left tibia stress fracture and bilateral fibular stress reactions.  The PEB chose a clinically appropriate code 5022 (periostitis) which defaults to the rating criteria of diagnostic code 5003 (arthritis, degenerative).  The evidence does not support painful motion, swelling, or muscle spasm of either leg for the minimum 10% rating.  The X-ray findings could not be used under this code as specified in the note (2) which states, “The 20% and 10% ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic code 5013 to 5024, inclusive.”  Therefore the Board agreed at the time of separation with a unilateral or bilateral pathology, the tibial stress fracture and fibular stress reactions condition meets a 0% non-compensable rating and the evidence does not support a higher rating even when considering the VA’s coding choice.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board concluded that there was insufficient cause to recommend a change in the PEB adjudication for the tibial and fibular stress fractures condition.

Contended Low Back Pain Condition.  The Board notes the PEB adjudicated the LBP condition with the lower abdominal pain condition subsuming them under the diagnostic code 7319.  The Board’s main charge is to assess the fairness of the PEB’s determination that LBP was not a separately unfitting condition if decoupled from the abdominal pain.  The Board’s threshold for countering fitness determinations is higher than the VASRD §4.3 (reasonable doubt) standard used for its rating recommendations, but remains adherent to the DoDI 6040.44 “fair and equitable” standard.  The LBP was profiled, was implicated in the commander’s statement, and was judged to fail retention standards when coupled with lower abdominal pain.  The service treatment record evidence reflects, 3 months prior to the NARSUM, the CI seeking care for just LBP without the constellations of other symptoms for the first time wherein she describes falling on her canteen in July 2002.  She received treatment with physical therapy and likely chiropractic care.  The range-of-motion (ROM) evidence at the time of separation reflects normal flexion, and limited extension, right and left lateral flexion, with increasing pain at the extremes of motion.  The STR evidence also reflects abdominal pain radiating to the back and flank pain which was evaluated in conjunction with the other constellation of symptoms that were diagnosed as IBS.  The medical member discussed that it was reasonable for the PEB to have considered the LBP as part of the IBS condition given the timeline and presentation of the symptoms.  The Board further agreed having decoupled the low back condition from the IBS condition that there was not a preponderance of evidence which would have made the condition separately unfitting.  All were reviewed by the action officer and considered by the Board.  After due deliberation in consideration of the preponderance of the evidence, the Board concluded that there was insufficient cause to recommend a change in the PEB determination for the LBP condition and so no additional disability rating is recommended.

BOARD FINDINGS:  IAW DoDI 6040.44, provisions of DoD or Military Department regulations or guidelines relied upon by the PEB will not be considered by the Board to the extent they were inconsistent with the VASRD in effect at the time of the adjudication.  The Board did not surmise from the record or PEB ruling in this case that any prerogatives outside the VASRD were exercised.  In the matter of the IBS condition and IAW VASRD §4.114, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the tibial and fibular stress fractures condition and IAW VASRD §4.71a, the Board unanimously recommends no change in the PEB adjudication.  In the matter of the contended LBP condition, the Board unanimously agrees that it cannot recommend it for additional disability rating.  There were no other conditions within the Board’s scope of review for consideration. 

RECOMMENDATION:  The Board, therefore, recommends that there be no recharacterization of the CI’s disability and separation determination, as follows:  

UNFITTING CONDITION	VASRD CODE	RATING	
Irritable Bowel Syndrome	7319	10% 	
Tibial and Fibular Stress Fractures	5022	0%	
COMBINED (w/ BLF)	10% 	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20120607, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans’ Affairs Treatment Record

	Physical Disability Board of Review

SFMR-RB									

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(TAPD-ZB), 

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for AR20130010776 (PD201201664)

I have reviewed the enclosed Department of Defense Physical Disability Board of Review (DoD PDBR) recommendation and record of proceedings pertaining to the subject individual.  Under the authority of Title 10, United States Code, section 1554a,   I accept the Board’s recommendation and hereby deny the individual’s application.  
This decision is final.  The individual concerned, counsel (if any), and any Members of Congress who have shown interest in this application have been notified of this decision by mail.

 BY ORDER OF THE SECRETARY OF THE ARMY:

Encl						
						         (Army Review Boards)

CF: 
(  ) DoD PDBR
(  ) DVA